General discussion 195 Comprehensive exploration of the implementation of clinical skills of IMR practitioners In this study, we were able to comprehensively explore the implementation of the clinical skills of IMR practitioners using two IMR fidelity scales. We identified specific clinical skills that needed improvement, including role-play, modeling, and home assignments. Therefore, we recommend specific additional training for IMR practitioners. Implementation of these recommendations may lead to more effects. This study may have provided some insight in possible working mechanisms of IMR Using a cross-sectional structural equation analysis of the baseline data (Chapter 4) and a mediation analysis using longitudinal data (Chapter 7), we provided insight into the possible working of IMR. Our results suggested that self-reported overallillness self-management is a stronger direct determinant of personal recovery than indirectly via clinical and functional recovery. Moreover, this study confirmed that improvement in clinical and functional recovery may not be a prerequisite for improvement in personal recovery. The effects found in this study are consistent with part of the conceptual framework on the working of IMR, suggesting that IMR would lead to improvement of illness self-management, and that improvement of illness self-management would lead to improvement of personal recovery. This possible association between illness selfmanagement and personal recovery is supported by the results of our mediation analysis (Chapter 7). Limitations Shortcomings in IMR implementation regarding fidelity and completion In our pilot study (Chapter 2) and RCT (Chapter 5), IMR implementation showed considerable shortcomings. Only approximately half of the participants completed the program. Furthermore, IMR fidelity was only fair to moderate for almost half of the participants. These shortcomings in IMR implementation may have led to underestimation of the outcomes. No control for a possible effect of peer-group support In this study IMR was offered in a group format and compared with usual care, which largely used an individual format. Therefore, a limitation of this study is that we could not control for the potential effects of peer-group support (27-30). When designing this study, we considered comparing the effects of IMR in a group format with those of another type of group. However, implementing an equal number of
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